Dr. Sise is a trauma surgeon whose job positions him for patients with high-risk behaviors and who believes methamphetamine use in San Diego has become a plague. He states, "You will inevitably die, whether directly or indirectly, from the use of methamphetamine." Dr. Sise feels treatment results are dismal, and the prognosis is worse than cancer. Given these extreme treatment difficulties, he encourages strong prevention programs to reduce first-time use.

Methamphetamine causes changes in the heart similar to a heart attack, such as arrhythmias and ventricular fibrillation. Other side effects include weight loss, increased risk of blood clots, stroke, hyperthermia, greater odds of becoming a victim of criminal activity and child abuse. Methamphetamine abuse also causes problems for society in terms of increased costs because most users have no health insurance and use public funds. A change in the demographics of addicts shows methamphetamine is now used more frequently by women, college students and white collar workers.

Alcohol is still the number-one drug of abuse, but methamphetamine is a close second in the San Diego area. Tolerance is a major problem; addicts need increased doses to get high, but paranoia starts at the same level. Due to hyperthermia and thermal positional asphyxia, methamphetamine also causes a syndrome known as "death in custody," which presents great problems to law enforcement. Methamphetamine also causes problems with fetal development in pregnant women due to decreased blood flow that strangles the placenta. Other problems include dystonia, lethargy, learning disabilities and premature growth retardation.

Three levels of methamphetamine addiction exist. Low-intensity users swallow or snort methamphetamine for weight loss or for shift-worker fatigue. Users often binge and become addicts who smoke or inject methamphetamine. Long-term, high-intensity users repeatedly binge to stop withdrawal pain.

Initial treatment is dependent upon the amount of drugs used. Mild intoxication requires reassurance and a quiet environment. Moderate intoxication requires a powerful sedative such as Valium. Overdoses are life-threatening situations due to the risk of strokes, heart attacks, and dehydration. Available preliminary data on treatment is discouraging. Long-term cure rates for methamphetamine may be less than 10 %, and statistics show high relapse rates six months after treatment. Behavioral treatments may only delay the inevitable return to methamphetamine use and addiction. Dr. Sise opines that we must develop a medication to "rescue" the brain from its state of neurotoxicity.

Are antidepressants helpful?

No; neurotoxicity of the brain lasts up to two years. The synaptic depletion that has occurred requires a return to normal dopamine and norepinephrine levels.

At what point is a person beyond rational decision making?

The very first time they use methamphetamine, and within one hour of using it. This is why we need to get to low-intensity users quickly before methamphetamine permanently affects the brain.

The 4-6 months we refer to as "the wall" is a period of protracted abstinence during which the brain recovers from the changes resulting from methamphetamine use. Our group at UCLA and the West Los Angeles VA is beginning a program of brain-imaging studies (PET scan) to assess the acute and chronic effects of methamphetamine abuse.

The Matrix Model requires staff to have treatment manuals which allow them to create explicit structure and expectations, to establish positive, collaborative relationships with patients, to teach information and cognitive-behavioral ideas and to positively reinforce behavior change. Treatment specialists must deliver information in small quantities because patients do not remember due to damaged short-term-memory skill. Staff must teach users not to use methamphetamine and to incorporate 12-step programs. Regular urinalysis testing is essential to monitor the use of methamphetamine and to learn if such monitoring is a deterrent.

It is vitally important to instruct patients on the effects of methamphetamine abuse on the brain. This helps the addict abstain long enough for the brain to recover. Treatment specialists must also teach patients about why they experience craving, about issues related to alcohol and marijuana use, and about problems with sexual behavior, all of which are affected by the brain.

Are these patients unemployed?

Yes, 70 percent are unemployed and on public assistance. Patients who are employed and have families usually have better outcomes.

Which are the largest sources of referrals?

Most referrals come from child-protective services, friends, and probation.

What about relapse?

Handling relapse is a natural part of treatment. Staff must decide what they can do differently for that patient, make needed adjustments, and increase the intensity of treatment.

There is a clear need to address the substance abuse problems of the incarcerated population. A 1995 BJS report stated 26 percent of all offenders under state correctional supervision had substance problems prior to their incarceration. Effective drug rehabilitation of this population can lead to reduced crime and incarceration costs.

The most used intensive treatment in state prisons is the therapeutic community (TC). It involves the maintenance of a support environment where the client is actively involved in his or her own therapy. It also contains a confrontational orientation to break down the client's denial so that the client can learn positive behaviors. Reports show these programs work, and they reduce recidivism. The Cornerstone Program in Oregon and Stay N'Out program in New York are good examples. The speaker recommended Kevin Early's Drug Treatment Behind Bars: Prison-Based Strategies for Change (1996, Praeger Publishers) as a reference.

TC experts recommend a program length of 9-12 months and a facility that separates the treatment program offender(s) from the general population. Additionally, male, female and special-needs offenders require separate programs. Continuity in the referral process is considered essential to program success, and there must be an assessment process that measures the severity of the addiction and motivation for treatment.

The TC program must develop genuine support from both security and treatment staff. Selection and training of high-quality staff are important to build the necessary cohesion. The program should have sound management information and evaluation systems. Transition is also part of the process. Effective rehabilitation programs can reduce recidivism and costs. A Texas study found that for every $1 invested in a Substance Abuse Felony Punishment facility, the state saved $1.50 in reduced incarceration costsa great return on taxpayer money.

DiscussionQuestions and Comments

What are your recommendations for research?

What are your recommendations for prevention and law enforcement policy?

How can we better integrate the criminal justice system with treatment providers?

Sustained treatment referrals from drug courts, law enforcement and emergency rooms are fundamental to success. Resources are scarce, capacity is limited, and reimbursement sources are fewwe must change this.

Law enforcement must be a partner in this effort. Court pressure, judicial training, and availability of medication are other important components.

We should concentrate resources to treat people of low-intensity use. We need emergency room protocols.

Mandatory treatment with a system of graduated sanctions, early detection devices like the breath test for alcohol and outcome research distributed nationally is needed.

Treatment should be available, accessible, diverse (including faith-based), well financed, and outcome-based.

Levels of care should include outpatient, residential, acute-care hospital, probation, and incarceration.

Referral points can include self, family, law enforcement, medical, workplace, schools, and the faith community.

Treatment is not always well respected, and mandatory minimum sentencing makes treatment difficult. Where is the support of judges and prosecutors?

Rural areas only have generic treatment services.

We must use the lessons learned from crack; methamphetamine use is not a racial issue.

Small communities have no support systems while Kansas City has five assessment centers where anyone can go and get a referral to treatment centers.